Questionnaire 21-004: Activities Within Iowa For A Corporation, Partnership Or Llc Page 9

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Page 9
I declare that the information furnished in response to this questionnaire is to the best of my knowledge
and belief, true, correct, and complete:
_______________________________________
Date
_______________________________________
Signature of Corporate Officer, Partner or Owner
________________________________________
Title of Corporate Officer, Partner or Owner
________________________________________
Preparer’s Name (print or type)
________________________________________
Preparer’s Title (print or type)
________________________________________
Preparer’s Signature
____________________________________
Preparer’s Phone Number
Mail the completed questionnaire to:
Iowa Department of Revenue
Examination Section/Compliance Division
PO Box 10456
Des Moines, IA 50306-0456
21-004i (04/04/11)

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